=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831649573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAAK MEDICAL SUPPLY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2016
-----------------------------------------------------
Last Update Date | 11/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 RESERVOIR CIR STE 102
-----------------------------------------------------
City | PIKESVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21208-1391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-978-8236
-----------------------------------------------------
Fax | 410-983-3950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 RESERVOIR CIR STE 102
-----------------------------------------------------
City | PIKESVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21208-1391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-978-8236
-----------------------------------------------------
Fax | 410-983-3950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. ZINOVIY FRADLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-629-5225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | R4000
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------